Men who never smoke live longer, better lives than heavy smokers

October 13, 2008

Health-related quality of life appears to deteriorate as the number of cigarettes smoked per day increases, even in individuals who subsequently quit smoking, according to a report in the October 13 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Smoking has been shown to shorten men's lives between seven and 10 years, according to background information in the article. It also has been linked to factors that may reduce quality of life, including poor nutrition and lower socioeconomic status.

Arto Y. Strandberg, M.D., of the University of Helsinki, and colleagues followed 1,658 white men born between 1919 and 1934 who were healthy at their first assessment, conducted in 1974. Participants were mailed follow-up questionnaires in 2000 that assessed their current smoking status, health and quality of life. Deaths were tracked through Finnish national registers.

During the 26-year follow-up period, 372 (22.4 percent) of the men died. Those who had never smoked lived an average of 10 years longer than heavy smokers (more than 20 cigarettes per day). Non-smokers also had the best scores on all health-related quality of life measures, especially those associated with physical functioning. Physical health deteriorated at an increasing rate as the number of cigarettes smoked per day increased, with heavy smokers experiencing a decline equivalent to 10 years of aging.

"Although many smokers had quit smoking between the baseline investigation in 1974 and the follow-up examination in 2000, the effect of baseline smoking status on mortality and the quality of life in old age remained strong," the authors write. "In all, the results presented here are troubling for those who were smoking more than 20 cigarettes daily 26 years earlier; in spite of the 68.9 percent cessation rate during follow-up, 44.1 percent of the originally heavy smokers had died, and those who survived to the mean [average] age of 73 years had a significantly lower physical health-related quality of life than never-smokers."

The findings may add to the view of smoking as a burden on society and might also encourage individual smokers to quit, the authors note. "The argument of better quality of life may be especially meaningful for the aging smoker but, as our results show, for the best health-related quality of life, the habit should not be started at all," they write. "The highly addictive nature of nicotine is revealed by the persistence of the smoking habit in spite of the declining health-related quality of life among older heavy smokers. For those not able to quit smoking, reduction may also be beneficial because mortality [death] and health-related quality of life showed a dose-dependent trend according to the number of cigarettes smoked daily."

Additional papers related to smoking in the October 13 issue found that:

Offering smoking cessation counseling to hospitalized smokers appears to be effective as long as supportive contacts are offered for more than one month after discharge. Nancy A. Rigotti, M.D., of Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues reviewed 33 trials of smoking cessation interventions that began during hospitalizations. Programs that offered telephone or in-person support lasting longer than one month improved smoking cessation rates six to 12 months after discharge. "Adding nicotine replacement therapy to counseling may further increase smoking cessation rates and should be offered when clinically indicated, especially to hospitalized smokers with nicotine withdrawal symptoms," the authors write.

Hospital-based smoking cessation programs, along with referrals to cardiac rehabilitation, also appear to be associated with increased rates of quitting smoking following heart attack. Nazeera Dawood, M.D., M.P.H., at Emory University School of Medicine, Atlanta, and colleagues studied 639 patients who smoked at the time of their hospitalization for myocardial infarction (heart attack). Six months later, 297 (46 percent) had quit smoking. The odds of quitting were greater among patients who received discharge recommendations for cardiac rehabilitation and those who were treated at a facility offering an inpatient smoking cessation program; however, individual counseling was not associated with quit rates.

A pay-for-performance program may increase referrals to tobacco quitline services, particularly among clinics who have not previously participated in quality improvement activities. Lawrence C. An, M.D., of the University of Minnesota, Minneapolis, and colleagues randomly assigned 24 primary care clinics to participate in a program offering $5,000 for 50 quitline referrals. Between Sept. 1, 2005, and June 31, 2006, these clinics referred 11.4 percent of eligible smokers, compared with 4.2 percent among 25 clinics offering usual care. "Quitlines are widely available, and application of pay-for-performance strategies to encourage health care provider referral should be strongly considered by health care organizations seeking to reduce the health and economic burden of tobacco-related disease," the authors write.

"Smoking remains the largest avoidable cause of death and disability in the United States, but it is a problem against which we are making steady albeit far too slow progress," writes David M. Burns, M.D., Del Mar, Calif., in an accompanying editorial. "Smoking cessation is one of the most important changes needed to achieve the goal so often articulated by Dr. Ernst Wynder, one of the founders of the field of preventive medicine: die young as late in life as possible."
(Arch Intern Med. 2008; 168[18]:1968-1974, 1950-1960, 1961-1967, 1993-1999, 1946-1947. Available pre-embargo to the media at

Editor's note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. To contact Nancy A. Rigotti, M.D., call Emily Parker at 617-724-6425. To contact corresponding author Susmita Parashar, M.D., M.P.H., call Jennifer Johnson at 404-727-5696. To contact Lawrence C. An., M.D., call Nick Hanson at 612-624-2449.

The JAMA Network Journals

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